Whatcom County

The Care Transitions Project of Whatcom County is a new initiative aimed at eliminating unnecessary hospital readmissions.

Studies across the country have demonstrated that there are potential gaps in communication and coordination when patients transition from one setting of care to another—resulting in patient risk and increased costs.

The aim of this project is to bridge those gaps, enabling safer and more effective care transitions for patients living in Whatcom County, Washington. A kick-off meeting for stakeholders was held on November 18, 2008. (Contact us to request a copy of the presentation slides.)

• Connect providers throughout Whatcom County's healthcare system, to enable safe and effective transition of patients
• Eliminate unnecessary readmissions to the local hospital (St. Joseph Hospital)
• Enable Whatcom County patients and their families to participate fully in their health and healthcare, particularly when leaving the hospital

To accomplish the goals, participants will:

• Engage healthcare providers to ensure optimal coordination, communication, and information exchange around the needs of each patient and family, particularly when patients are leaving the hospital. Activities include identifying patients at highest risk, using the CMS CARE tool, and implementing the teach-back technique.
• Implement the use of care transition coaches and coaching protocols to help patients self-manage their care.
• Expand use of the Shared Care Plan Personal Health Record among Whatcom County residents.
• Activate strategic partnerships that engage local healthcare, business, nonprofit, and government entities in the Care Transitions Project.